Rudolf Virchow and social medicine

Some random history for today:

I always thought Rudolf Virchow was an interesting physician. Granted he didn't believe in Darwinism or antisceptics, but he did have a great faith in medicine as a tool to lift the condition of communities. Virchow is credited with the founding of "social medicine" positing that disease is never purely biological, but often, socially derived.

I came across this page of his quotes and especially liked this one:

"Medicine is a social science, and politics is nothing else but medicine on a large scale. Medicine, as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution: the politician, the practical anthropologist, must find the means for their actual solution."

I leave it to you to determine this quote's modern day significance.

U.S. Health Care Reform Interactive Timeline

Noticed this on NEJM today - neat little interactive graphic on the history of health care reform with links to the relevant NEJM articles from that time.

Health Care Reform 2009 | U.S. Health Care Reform Interactive Timeline

of note, there is an interesting cadence to these efforts - a push for reform, followed by years of stability / status quo - granted you don't want to reform constantly, or too disruptive to system. But regardless, pretty much every other year for the last 50 years a health care bill has been passed.

This American Life series on health care

If you haven't listened to it already - This American Life has a two part series on health care in the US. Co-produced with NPR/Planet Money group (involved w/ the Baseline Scenario bloggers that I quoted the other day)

This American Life - part one
This American Life - part two

Calvin Trillin’s Theory, the financial crisis and health care mamangement

Calvin Trillin’s Theory at The Baseline Scenario:

Not directly health care related, but the chart when you follow this link is fantastic. Follow through with me on this and you'll see where I'm going (health care, like finance, has become too complicated for the old guard).

Recent Trillin op-ed recounted a fictional encounter where the interrogator asks what happened on wall st and the interviewee states smart people took over wall street.

"Then, however, as college debts and Wall Street pay grew in tandem, the smart kids started going to Wall Street to make the money, leading to derivatives and securitization, until finally: “When the smart guys started this business of securitizing things that didn’t even exist in the first place, who was running the firms they worked for? Our guys! The lower third of the class! Guys who didn’t have the foggiest notion of what a credit default swap was.”

In the blog link, there's an interesting point about how what's valued in CEO succession, doesn't necessarily lead to a good CEO. "Even when you don’t have the generational issue that Trillin talks about, the problem is that the sociology of corporations leads to a certain kind of CEO, and as corporations become increasingly dependent on complex technology or complex business processes (for example, the kind of data-driven marketing that consumer packaged companies do), you end up with CEOs who don’t understand the key aspects of the companies they are managing."

I wonder if this is an issue in health care. Has health care delivery become so complex, doctors are so disengaged from the process of health care management and reform, that we've slowly gotten ourselves into the current mess that we are in?

I'm really stretching the parallelism here, but I wonder if there is something to it. That's why I guess I'm such a big fan of giving more power to MedPAC - a technocratic body that is independent from politics, and infused with seemingly intelligent and capable health care reform thinkers.

High-Deductible Health Plans

An article in yesterday’s New York Times discusses the composition and relative merits of high-deductible health plans, which are most often paired with George Bush's favorite cost-containment vehicle, the Health Savings Account. Despite the bitter taste in my mouth when I think about our former president (blech!), I think that high-deductible health insurance plans do have some merit.

First, let's ask ourselves what the point of insurance is. Sounds obvious, but health insurance has metamorphosed into a creature nothing like life insurance or car insurance. In the latter, you pay a premium and if something happens, you first pay a deductible and then, for catastrophic accidents, you get full coverage. Interestingly, having this deductible actually promotes health, sorry car, maintenance activities. After all, you'd rather shell out 20 bucks for an oil change than the 500 dollars for a new transmission down the road - not to mention your car runs smoother in the meantime. Health insurance should really function the same way: you pay premiums and if something really horrible happens, you get totally covered after you surpass the deductible. The way most traditional plans work now, you continue to pay a percentage of costs when your bone marrow transplant costs $1 million, which is why healthcare debt is the leading cause of bankruptcy in the country. Because they cover such unlikely events, high-deductible plans can afford to have cheaper premiums since they make more money on the front end than they lose on the back end.

High deductible plans are meant to reduce the effects of “moral hazard,” which is the notion that people will use more of a good if they are shielded from the costs of consumption. As has been described on these pages, Americans are voracious consumers of healthcare, so perhaps exposing consumers to some of the costs, while not thoroughly penalizing them if something untoward happens, might reduce spending. Alas, health is not like car maintenance, and people have little insight into how health promoting activities may lead to lower financial (not to mention emotional and physical) costs down the road. Because health is so opaque for consumers, they might be willing to defer that colonoscopy if it means they have to shell out $1000 dollars. Furthermore, many of the benefits of health promoting activities wouldn’t accrue to the health plans, but probably to Medicare. Insurance companies, therefore, have no incentive to subsidize “good” behavior now if the beneficiary is the government 20 years from now.

So, this is where the Health Savings account fits in. High-deductible plans paired with HSA's benefit consumers because a) it's a pre-tax contribution and b) employers will often chip in the first $500 to $1000 dollars, and c) HSAs are portable and you never lose what you put in. The HSA is intended to offset the moral hazard problem with high-deductible plans - again, that irrational consumers will avoid costly health promoting activities like skin checks if they have to pay any proportion of that out-of-pocket. Contributing to the HSA is purely voluntary, though, and I suspect those who are trying to save money aren't likely to build a battle-chest of money in case they get sick.

From a pure economics standpoint, these plans make sense. For them to work for everyone, though, I think policy makers have to force insurers to provide basic stuff like checkups, Pap smears, mammograms, etc. for very low or even free prices.

Challenging the Assumption that Costs Always Rise

In this week's New England Journal, David Cutler, an economist and adviser to the White House, lays out a pretty solid argument for why costs might not rise in the future, even without health payment reform. Our prevailing assumption has been that health care costs will continue to rise, at a pace faster than GDP, until health care bankrupts the nation.

Cutler contends this might not be true based on three core ideas:
1) Technology: the rapid rise in health care costs over the past 10 years has been largely fueled by innovations in pharmaceuticals and medical devices. Cutler points out that the pipeline for new technologies is starting to dry up, and increasing imaging costs might be mitigated by imaging benefit managers akin to pharmacy benefit managers. A formulary for how to diagnose knee pain might not be far off. Further, he notes, profitable new technologies tend to draw lots of competitors, so cost growth is likely to be offset by increased substitution effects.
2) Health IT: Obama's plan to increase spending on EMR's and decision support may cut out huge amounts of wasted time in paperwork and administration, not to mention cut costs from duplicated diagnostic testing.
3) Chronic Disease Management: this one's a little trickier for me (see Sree's last post), but Cutler suggests that by improving disease management, we prevent readmissions and therefore reduce acute care costs. Whether these savings are offset by increased life expectancy is yet to be determined.

Overall, I found this article pretty well researched and thought out and I'm reassured that our Doomsday scenarios might not come to pass. That said, I'm kind of glad it looks like health care spend is on the uptick, because it means policymakers are more likely to pass substantial health care reform in the near term.

Primary care and the health care cost curve

Guys, I need to submit a blog post to policy2.org to kick start a conversation amongst policy makers and academics on the role of primary care in health reform. Specific question I was asked to answer was "how does primary care bend the cost curve". This is my response - can you give me some feedback in the next 18hrs? Argument flow is weak at points. Doesn't need to win any awards - just start conversation. Need to submit by end of work day tomorrow:

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Expanding primary care will not bend the cost curve.

All primary care doctors do is postpone the time of eventual death. The patient lives longer and ultimately develops new and more costly diseases that are the consequences of aging.

Ever heard these arguments? I have and it’s fascinating. Intuitively, this makes sense to me. In the cold calculus of economics, good primary care will prevent disease and extend life. As they say, taxes and death are both inevitable. And death costs money, and I have to believe death when you are older is more costly than death when you are slightly younger.

I’m making two huge sweeping assumptions here. First - Primary care saves lives. Second – Death when you are older costs more money to the system. I did a quick literature search to challenge these assumptions.

So let’s question the first assumption – does primary care save lives?

Mackinko et al.did an interesting little interesting literature review in the International Journal of Health Services in 2007. They pooled together a series of studies, re-cut the data in order to assess primary care effect size and the predicted effect on health outcomes of a one-unit increase in primary care physicians per 10,000 population. What they found was interesting - Primary care physician supply was associated with improved health outcomes, including all-cause, cancer, heart disease, stroke, and infant mortality; low birth weight; life expectancy; and self-rated health. Pooled results for all-cause mortality suggested that an increase of one primary care physician per 10,000 population was associated with an average mortality reduction of 5.3 percent, or 49 per 100,000 per year. Not bad.

I am assuming this is not surprising. Primary care physicians include family medicine doctors, internists, pediatricians, and in some instances, obstetrician–gynecologists. Currently, primary care accounts for about one third of the physician workforce in America. For many, primary care physicians are the first contact for a person with an undiagnosed health concern, they provide patients with the opportunities to prevent disease and they offer continuity and coordination of care for many complex conditions. Given their pivotal role in delivering care, it follows reasonably that they will save lives.

Now the second question – does primary care save money?

This is the tricky one. But one of my favorite studies on this question is from Lubitz et al. from his New England Journal article entitled “Health, Life Expectancy, and Health Care Spending among the Elderly” in 2003. They found that elderly persons in better health had a longer life expectancy than those in poorer health but had similar cumulative health care expenditures until death. A person with no functional limitation at 70 years of age had a life expectancy of 14.3 years and expected cumulative health care expenditures of about $136,000 (in 1998 dollars); a person with a limitation in at least one activity of daily living had a life expectancy of 11.6 years and expected cumulative expenditures of about $145,000.

Goetzel had an interesting framing of this question in his 2009 Health Affairs article: “Providing certain preventive services, mostly in clinical settings, does not save money. But, then again, neither do most medical treatments. The issue relevant to this debate is how much value is achieved for any given preventive or treatment service. Instead of debating whether prevention or treatment saves money, we should determine the most cost-effective ways to achieve improved population health, and where to focus scarce resources to get the "biggest bang for the buck."

Note that I did not ask “does prevention save money?” If asked, I’m not sure I could defend the assertion that “prevention saves money.” For example, screening costs can exceed the cost of treatment if only a small portion of a population would get sick without any preventative services. As a society, it might be cheaper to simply treat, and not always prevent.

The question I asked, however, was “does primary care save money?” The role of the primary care physician is not just prevention. Not to be heavy-handed, but I do believe they are the guardians of health – they help the patient navigate the complex decisions of life and health – of prevention and treatment. I believe this is how the primary care physician helps control costs – by helping patients make rational decisions about their care, and providing the longest and healthiest life as possible.

These are just some quick thought starters. I now hand the conversation over to you. I encourage you to use Policy2.org to more fully engage each other, challenge and explore the data, and construct the story that helps us tell the American people that primary care physicians play a vital role in creating a healthier country with greater economic opportunity for all.

Lobbyists Pull the Teeth out of Health Care Reform

An article in today's New York Times describes the frantic efforts of lobbyists to limit payment reform and hinder policymakers efforts to curb the spiraling cost of health care.

One of the most obvious reforms that's been proposed would be to tax high cost health plans which fuel rising costs because employers are more willing to accept higher premiums when they're tax free. Employees, generally unaware of the cost of health insurance, remain in the dark about what their employers are paying and therefore have no incentive to limit costs themselves. Congress has appropriately considered taxing so-called "Cadillac" plans in an effort to direct employers to purchase less costly health insurance plans and expose consumers to more of the costs. Naturally this check on rising costs is being challenged by the interests that have the most to lose - hospitals, doctors, and insurance companies. Ironically, big-labor has also opposed the reforms even though it would mean employers may pass on the savings in the form of increased wages. The CBO has given this initiative high marks in terms of cost-saving, yet lobbying efforts threaten to kill this part of the bill in committee.

The second major reform is to set up a non-partisan independent Medicare Commission, which seems a lot like the NICE in the UK. The commission would finally leverage Medicare's significant purchasing power to negotiate prices for drugs and negotiate lower costs with hospitals. Drug companies have negotiated only $80 billion in cost reductions over 10 years, which not only represents a drop in the bucket in terms of overall profits, but actually protects them in the long run. By agreeing to small losses, they would actually be protected from further cuts by the Medicare Commission even if five years from now there are major benefits to be extracted. Likewise, hospitals and the AMA are vigorously opposing the $155 billion in reductions to hospital and physician payments even though bloated, inefficient, and often profitable groups working essentially in a cost-plus environment currently have no incentive to limit their costs. What's left? Pilot programs in coordinated care, health IT, and comparative effectiveness (which get seriously dinged by the CBO).

This is just sad, and it's not just Republicans - Democrats in the House are being maneuvered, too. The Baucus bill that represents the only real change in the status quo is being so ticky-tacked that it's going to come out totally ineffective. I understand the need to pass something with some sort of bipartisan appeal, but what's the point if it can't effect any real change? The fact that our political process can't put together something that benefits citizens instead of the influential people that fund campaigns is absolutely pathetic.

Death of Wyden-Bennett

Jeff Greenberg first turned my attention to the Wyden-Bennett bill - and after reading it, I always thought it was a very good proposal for health care reform. David Brooks actually has a v. good op-ed piece today on the Baucus bill and Wyden/Bennett

Op-Ed Columnist - The Baucus Conundrum - NYTimes.com

More of a description on W/B is in the link from Brooks. But essentially one of my main concerns with the current insurance market and reasons to support W/B is the following:

1) Insurance in America is tied to employment
2) Most Americans switch jobs every few years (~5-15 jobs lifetime)
3) This in turn means that Americans switch their insurance company every few years (in the past decade I have switched insurance companies three times, average time with an insurance company is ~3-7yrs)
4) Insurance companies have little incentive to try to promote health preventative behaviors since all that benefit would accrue to another insurance company, and ultimately Medicare (where we will all get our insurance from eventually).
5) If you decouple insurance from employment and create an insurance exchange market (key elements of W/B), then insurance companies are more likely to have customers for a longer time, thus create sane products that promote healthy behaviors so they can accrue some of the cost benefit (while improving the lives of their customers)

Unfortunately, it seems the W/B is a no-go. And the question remains - to support Baucus bill or not...

NEJM -- The Cost of Health Care -- interviews by Atul Gawande

Worth a scan. Gawande interviewing academics on health reform from New England Journal of Medicine this week -

NEJM -- The Cost of Health Care -- Highlights from a Discussion about Economics and Reform

Primary care shortage in the setting of expanding access

I was recently asked to comment for the Hope Street Group on what impact primary care would experience from expanding insurance access. There was an NY Times article about the Massachusetts reform effort.

In Massachusetts, Universal Coverage Strains Care - New York Times

Here was the initial outline I jotted:

• Our nation faces an unprecedented primary care shortage with or without reform

• Increasing health coverage for the uninsured could rapidly increase the future primary care supply gap from ~12k PCP-equivalent FTEs to ~29-68k PCP-equivalent FTEs by 2015 (equivalent to a 10-25% increase in today’s supply), and will add particular strains to the primary care system
• Even in the absence of reform, a shortage of ~12k FTEs (equivalent to a 5% increase in current supply) is projected by 2015
• To serve the 56 M projected uninsured in 2015, 17-56k additional FTEs would be needed, with additional strains on the system due to the unique demands of the uninsured
• Primary care shortages are driven by mismatches in supply and demand that are not immediately addressable through market forces
• Demand drivers include
• Total population growth
• Aging population
• Growing prevalence of chronic conditions
• Supply decreasing due to
• Difficult to ramp up supply: Requires 7 yrs of postgrad training before entering health system
• Compensation gap: Specialists paid 2-3 times more than PCPs
• Difficult to control lifestyle: desire for more “controllable lifestyle” with -2% YoY decline in family medicine residency entrants
• The case study of Massachusetts health reform provides key lessons to keep in mind – in particular, the critical need to address the initial demand surge as the newly insured enter the system, the risk of a “downward spiral” as PCPs become overstretched, and the need for transitional assistance to underserved areas
• The uninsured demand on primary care has specific implications – it will exacerbate the issue of underserved areas, and it will require a geographic redistribution of resources and an immediate surge in PC supply as the newly insured enter the system

Cost Savings at the End of Life - can primary care make a difference?

I was recently asked to comment on what effect does "end of life" care have on the rise of health care costs in the US. probably the most relevant article that E. Emanuel (in White House currently) wrote a decade ago.

JAMA -- Abstract: Cost Savings at the End of Life: What Do the Data Show?, June 26, 1996, Emanuel 275 (24): 1907

My thoughts are below:

1) There is nothing inherently wrong with spending a majority of your money for inpatient care in the last years of life. The more appropriate questions are 1) is the percentage of money spent the right percentage of money overall spent and 2) is the rate of inflation for end of life costs in line or out of line with other expenditures.

When you look at the work that the McKinsey Global Institute did, we found that the major driver of health care cost inflation was outpatient delivery of care - not inpatient care.

2) Outpatient medicine accounts for more than 40 percent of overall health care spending and 68 percent of spending above expected compared to other OECD countries. This category expanded at 7.5 percent per annum from 2003 to 2006—a faster pace of growth than observed in any other cost category—to add more than $166 billion in costs during this period.

3) Inpatient care costs account for 25 percent of overall health care spending but only 6 percent of total spending above expected ($40 billion). This category grew by 6.0 percent annually (trailing GDP growth), or $73 billion, from 2003 to 2006.


End of life issues are tricky - they raise a lot of emotions. But if we look at this purely from a data perspective, the heart of the cost problem is in outpatient care. So yes, you could argue that there is an imperative to reform end of life care since they consume a majority of costs on the inpatient side. But the elderly (=Medicare) spend a large portion of their medical lives admitted in the hospital. And that's okay, in my opinion. If our goal is to bend the cost curve, we should focus on outpatient, not inpatient, care.

Can primary care help reduce the inpatient end of life care costs? I think so - I don't know the data as well. But my hypothesis would be that 1) people at end of life do not make rational informed choices about the care they wish to receive (living wills, care directives, durable power of attorney) and thus 2) they receive more care than they would have wished, but they are too sick to express their views (e.g. stroke patient on life support who would not have wanted to have been on life support). If primary care could provide greater information about what options are available at end of life, people could make more informed decisions. This is what the whole "death panel" issue was about. If these policies could be promoted in a way that ensures a means for patients to exercise their autonomy on end of life issues and are not coerced, then to me this obviously makes sense.

Smooth and Predictable Aid for Health

I just read this fairly interesting article on global health financing.

Smooth and Predictable Aid for Health: A Role for Innovative Financing? - Brookings Institution

The paper's thesis is that financial aid flow to developing world health sectors are volatile - the terms of making and delivering future commitments of financial aid from donors to donor recipient is uncertain, and therefore makes it poorly suited to fund recurrent health care costs. In english - Cameroon might get $120M one year in aid and $20M in aid the next year, making it hard to know when to buy vaccines, when to invest in human capital, etc - without a predictable flow, health ministers have a hard time allocating funds to projects to ensure they are sustainable.

Another interesting observation in the paper is that when external aid falls in a country, internal expenditures in health fall to an even greater extent. For example - if external aid falls 10%, the country's government will spend 15% less of its own budget on health than the previous year.

The paper argues that there are opportunities to use interesting financial vehicles to smotth out aid flos to make them more predictable. The author suggests that the potential (1) smoothing of irregular aid commitments through securitization of aid receivables; (2) health endowment funds; (3) a swing donor facility; and (4) a “health debit card” for financing shortfalls.

Financial tools have become increasingly sophisticated, and I like the idea of securitizing and creating financial cushions that can help smooth aid flows for countries that have reliable financial and health track records. This is happening already, but I have to imagine not as much as could happen to prevent these unfortunate consequences.

Thai HIV Vaccine Trial Results are Mixed at Best

The huge NIH/Army HIV vaccine trial using the combination of two previously failed vaccines reported its results last week. The findings were in some ways very encouraging - there was a 1/3 reduction in new HIV cases in the group that received the vaccine when compared to the group that didn't. That said, the numbers were very very small with a three year incidence of 0.925% in the control group versus 0.6375% in the group that received the vaccine. With such small numbers, as some critics have pointed out, a tiny amount of statistical fling could have easily made this trial a total waste of $105 million of US taxpayers money. Not to mention, in terms of biology, there was no difference in terms of viral load in the two groups (suggesting that the vaccine didn't really boost immunity in any significant way). Finally, most vaccines result in at least an 80% reduction in incidence before people will spread them widely.

I wonder why they would have even done this trial in the first place. That is, who would have even thought this could have worked? Granted, the two vaccines were working in different ways, but to invest such huge sums of money when there was little likelihood of a real impact seems very short sighted. I suppose the international community so hungry for a breakthrough therapy for HIV, they'll pretty much fund anything...

Swiss Model for Health Care Is Gaining Admirers - NYTimes.com

I always find these comparisons misinformed. How can you compare a small country w/ a relatively homogenous population (ethnically and by gini coefficient of income distribution) with a country as diverse as the US?

Swiss Model for Health Care Is Gaining Admirers - NYTimes.com

In my opinion, the right comparisons are the NHS, France, Germany.